October/ 2019

Department of Health Research

Ministry of Health and Family Welfare, Government of India

Standard Treatment Workflow (STW) for the Management of

ST ELEVATION MYOCARDIAL INFARCTION (STEMI)
ICD-10-I21.3

CONSIDER ANGINA IF ACUTE CORONARY SYNDROME:

• Diffuse retrosternal pain, heaviness or
constriction 1. Angina at rest or lasting more than 20 minutes
• Radiation to arms or neck or back 2. Recent worsening of stable angina (crescendo) to CCS
• Associated with sweating class III
• Easily reproduced with post-meal exertion
• Consider atypical presentation: Exertional 3. New onset effort angina of less than 1 month in CCS class
fatigue or breathlessness or profuse II/ III
sweating or epigastric discomfort/ 4. Post infarction angina
syncope
ECG: If ST Elevation: Follow ST Elevation MI (STEMI) protocol
More likelihood if known patient of CAD/ If no ST Elavation: UA/NSTEMI
multiple risk factors
ANGINA UNLIKELY IF:
Variable Long lasting (hours to Restricted to areas Localized Pricking or piercing Precipitated by
location or days) or short lasting above jaw or to a point or stabbing type of movement of neck or
characteristic (less than a minute) below epigatrium pain arms or respiration

PATIENT WITH STEMI WITHIN 12 HOURS

ECG REVEALS ST ELEVATION MI* GENERAL MEASURES

Refer to primary angioplasty/ 1. Admit in ICU equipped with continuous ECG monitoring & defibrillation
thrombolysis capable hospital 2. Routine bio-chemistry and serial cardiac enzymes (troponin)
3. Pain relief by opioid
4. O2 if saturation less than 90%
*Includes new onset LBBB 5. Aspirin 325 mg, Clopidogrel 300 mg and Atorvastatin 80 mg
6. Echocardiography, particularly for mechanical complication

.in
PCI CAPABLE HOSPITAL PCI INCAPABLE CENTRE
A. Tranfer to PCI capable hospital if PCI can be performed within 120 min
1. Proceed for PCI
2. Radial route preferred B. If Transfer to PCI capable hospital not feasible
3. Preferably within 90 minutes THROMBOLYSE
1. Within 12 hours of symptom onset, if no contra-indication
DURING PROCEDURE 2. Preferably with fibrin specific agent Tenecteplase/ TPA/ Reteplase or Streptokinase,
if fibrin-specific are unavailable
rg
1. Use unfractionated heparin 3. Therapy to be started within 10 min preferably
2. No routine thrombosuction
3. Tackle culprit artery only unless shock
POST THROMBOLYSIS
1. ECG to be done at 60-90 min after starting thrombolysis to assess whether thrombolysis
4. DES to be preferred
is successful ( >50% ST settlement with pain relief) or not
2. If successful, transfer patient for PCI within 3-24 hours
POST PROCEDURE
3. If thrombolysis failed, transfer patient immediately for PCI capable hospital
r.o
4. Enoxaparin (preferred over unfractionated heparin) to be continued till PCI OR discharge
1. Continue dual antiplatelets for at least 1 year

LOOK FOR OTHER Unequal or absent peripheral pulses Dissection of Aorta

CAUSES OF CHEST
Respiratory evaluation Pleuritis/ Pneumonitis/ embolism/ pneumothorax
PAIN (ONGOING OR
m

WITHIN 12 HRS) Pericardial rub

Neuralgia or herpes

PATIENT WITH STEMI IN 12-24 HOURS

.ic

Transfer to PCI capable hospital immediately If ongoing pain, thrombolysis and transfer immediately

PATIENT WITH STEMI AFTER 24 HOURS

Angiography with a view to PCI only if any of following/ Contra indications of angiography:

Recurrent anginal Mecahnical Dynamic ST-T Life threatening

pain not controlled Cardiogenic shock Acute LVF ventricular
complication changes
w

by medical therapy arrhythmias

ABSOLUTE CONTRA-INDICATIONS TO THROMBOLYIC THERAPY:

Previous intra-
Ischemic stroke Recent (within 1 Recent (within 1 Known bleeding Severe
st

cerebral CNS neoplasm or Aortic dissection

in last 6 month) major month) major GI tendency (except uncontrolled
hemorrhage or stroke of AV malformation
months trauma/ surgey/ bleed menstrual bleed) hypertension
unknown
etiology head injury

DRUGS & DOSAGE STEMI DIAGNOSIS*

Anti-platelets Anti thrombotics:
1. Aspirin: Loading dose 325 mg followed by 75 mg OD 1. Unfractionated heparin: Bolus
2. Clopidogrel: Loading dose 300 mg followed 75 mg OD of 60 U/Kg (maximum 5000 U)
EMS or non
3. Prasugrel: Loading dose 60 mg followed by 10 mg OD followed by 12 U/Kg hourly Primary-PCI primary-PCI
4. Ticagralor: Loading dose 180 mg followed by 90 mg BD infusion to maintain APTT at capable centre capable centre
Anti-ischemic: 50-70 sec
Metoprolol: 2. Enoxaparin: 1 mg/Kg SC 12 hrly
Short acting: 25-100 mg BD
Preferably
<60 mins PCI possible
<120 mins?
Long acting: 25 -100 mg OD Thrombolyic Therapy:
Nitrates: Tenecteplase
Immediate
transfer to
PCI centre
Isosorbide mono-nitare 20 to 60 mg in 2 divided dose 35 mg IV bolus if 60-70 Kg Primary PCI Yes No
Nitroglycerine sustained release 2.6 to 6.5 mg BD 40 mg IV bolus if 70-80 Kg Preferably
<90mins
Nitroglycerine IV 5-25 mcg/ min infusion 45 mg IV bolus if more than (<60 mins) in
early
Statins: 80 Kg Rescue PCI
presenters

High dose Atorvastatin 80 mg OD Reteplase Preferably

within
Ace-inhibitor 10 mg IV bolus, repeat after 30 mins

Ramipril 2.5 -10 mg OD 30 min Immediately

Enalapril 2.5 -10mg BD Alteplase

Oxygen: 15 mg IV bolus followed by
If oxygen saturation below 90% 0.75 mg/Kg over 30 min upto No Successful Immediate
Yes fibrinolysis fibrinolysis
Morphine: 50 Kg weight, then 0.5 mg/Kg Immediate
transfer to
Titrated in a dose of 2-4 mg IV every 15 minutes over 60 min up to 35 mg PCI centre

Beta-blocker: Streptokinase Preferably

Oral beta-blocker if LVEF is less than 40% 1.5 million units IV over 60 3-24 hours
*The time point the diagnosis is
min confirmed with patient history &
ECG ideally within 10mins from
Coronary the First Medical Contract (FMC).
angiography All delays are related to FMC.

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and
are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by
the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.